Instructions on How to Fill in out SPring-8 Radiation Worker Registration Form (Form 5-1)
All SPring-8/SACLA users are required to be registered as radiation worker on a fiscal year basis (from April 1 to
March 31 of the following year). The registration complies with the Japanese Law. To be radiation worker at
SPring-8/SACLA, you must submit the Form5-1(mail the original Form 5-1 or e-mail its PDF) by 10 days before you
visit, and view a 30-minute long video instructing SPring-8/SACLA Safety rules upon arrival at SPring-8/SACLA.
Once registered, submission of this form is not required for return visits within the same fiscal year. If your affiliation
has changed during the fiscal year, you are required to terminate the registration and register again; please submit
a "Registration Termination Form" (Form 5-2) and a new Form 5-1 without delay. Please note that you are not permitted to carry out experiments at the SPring-8/SACLA unless registered as a SPring-8/SACLA radiation worker.
Radiation Worker Registration Form
(Registration Application for FY
Form 5-1
)
Date of Recent Radiation Safety Training
To be Radiation Worker at SPring-8/SACLA, take radiation
Fill in All Fields! and
safety training at your home organization and fill in the
Date of Submission(MM/DD/YYYY):
PRINT or TYPE in English
date of the training. The training is valid for one year; so
Applicant
please make sure that the scheduled date of SPringName:
ID#:
title
last name
first name
mid init
User card number 8/SACLA visit is within the validity period.
You may be exempted from the radiation safety training if
Gender: □M □F
Signature:
Date of birth:
MM/DD/YYYY
your radiation protection supervisor can certify that you
Affiliation:
possess sufficient knowledge and skills necessary for
handing radioisotope and working with ionizing radiation;
Div./Dept.:
in such case, please fill in the date when the exemption
*Date of recent radiation safety training (MM/DD/YYYY)
was made.
*Date of recent medical examination for radiation worker (MM/DD/YYYY)
Scheduled date of SPring-8/SACLA visit(MM/DD/YYYY)
Experience using SPring-8/SACLA : □Yes(previous radiation worker registration at SPring-8/SACLA : FY
Date of Recent Medical Examination for Radiation
Worker
(The receiver should belong to the radiation management section or the labor management section.)
To be Radiation Worker at SPring-8/SACLA, undergo a
Scheduled
Date
of
SPring-8/SACLA
Visit
Receiver:
medical examination prescribed by Japanese law (See
EnterAffiliation:
a date when you are available to
Div./Dept.:
a.-d. below) at a medical institution, have your organizaattend SPring-8/SACLA Safety Training
Address:
tion confirm that all results are normal and provide the
required by the Japanese law.
Telephon:
e-mail
date of the medical examination. The results are valid for
*The date should be 1 year before the scheduled date of SPring-8/SACLA visit.
one year. Please note that if the date is not appropriate,
*Application become invalid if the term between the date and the actual date to visit SPring-8/SACLA is over 1 year
after submitting this form.
we will contact you for verification.
□No
Applicant’s radiation dose report is sent to this address.
I hereby certify that:
1.
2.
3.
YYYY
[Examination Components Required by Law]
The above applicant has completed radiation safety training
a. Interview with a doctor: history of previous radiation
The applicant has undergone medical examination and was certified fit to commence working ionizing
radiation.
exposure, subjective symptoms
The applicant’s occupational dose history records show that the radiation dose to the applicant is kept
below the annual dose limit of 5 mSv/y. The applicant will submit the history records upon request.
b. Blood test: hemoglobin or hematocrit level, red blood
Radiation Protection Supervisor
(or Division/Department Head)
name
Signature
date
I have given the above applicant permission to perform radiation work at SPring-8/SACLA.
cell count, white blood cell count and differential count
c. Skin test
d. Eye examination (screening for cataract)
Organization Name:
Division/Department Head:
name
登録日
Signature
安全管理室長
放射線
防護管理者
担当者
RIKEN Harima Branch
Contact:
Submission and Questions regarding Required Forms
SPring-8 Users Office, JASRI
email: [email protected]
Questions regarding Information Required on Form 5-1
SPring-8 Safety Office, JASRI
email: [email protected]
date
JASRI
利用業務部
Signature of Radiation Protection Supervisor
Obtain the signature of your radiation protection supervisor
responsible for managing and ensuring records of your
radiation dose history, radiation safety training sessions and
medical examinations for radiation workers. If your organization does not have such radiation protection supervisor,
the signature of your div./dept. head is substitutable.
Radiation Worker Registration Form
(Registration Application for FY
Fill in All Fields! and
PRINT or TYPE in English
Form 5-1
)
Date of Submission(MM/DD/YYYY):
Applicant
Name:
ID#:
title
last name
first name
Signature:
mid init
User card number
Gender: □M □F
Date of birth:
MM/DD/YYYY
Affiliation:
Div./Dept.:
*Date of recent radiation safety training
(MM/DD/YYYY)
*Date of recent medical examination for radiation worker
(MM/DD/YYYY)
Scheduled date of SPring-8/SACLA visit(MM/DD/YYYY)
Experience using SPring-8/SACLA： □Yes(previous radiation worker registration at SPring-8/SACLA：FY
YYYY
□No
Applicant’s radiation dose report is sent to this address.
(The receiver should belong to the radiation management section or the labor management section.)
Receiver:
Affiliation:
Div./Dept.:
Address:
Telephon:
e-mail
*The date should be 1 year before the scheduled date of SPring-8/SACLA visit.
*Application become invalid if the term between the date and the actual date to visit SPring-8/SACLA is over 1 year
after submitting this form.
I hereby certify that:
1.
2.
3.
The above applicant has completed radiation safety training
The applicant has undergone medical examination and was certified fit to commence working ionizing
radiation.
The applicant’s occupational dose history records show that the radiation dose to the applicant is kept
below the annual dose limit of 5 mSv/y. The applicant will submit the history records upon request.
Radiation Protection Supervisor
(or Division/Department Head)
name
Signature
date
I have given the above applicant permission to perform radiation work at SPring-8/SACLA.
Organization Name:
Division/Department Head:
name
登録日
安全管理室長
Signature
放射線
防護管理者
RIKEN Harima Branch
担当者
date
JASRI
利用業務部